[At the beginning of the third millennium: what kind of surgery, what kind of surgeon?].

Technological progress and the evolution of biological knowledge lead us to expect major developments in the fields of organ replacement, minimally invasive surgery and tumour therapy in the coming decades. It is widely believed that xenotransplantation may offer a possible solution to the problem of the current chronic shortage of donors, though their use at present encounters formidable immunological obstacles, particularly as regards discordant transplants. Genetic engineering and the realisation of transgenic donors as well as new strategies aimed at modifying the immune status of the donor may well be the key to new developments in this sector. Selective culturing of tissues and the production of totally implantable artificial organs are additional lines of research which may provide useful means of meeting the increasing demand for organs. The enormous advances made in the field of high-tech solutions applied to the biomedical disciplines are destined to open up new frontiers in diagnostics, operating technique and the permanent training of surgeons. In particular, we are about to witness an extension of the use of computer technology and robotics, embracing the simulation and reproduction of virtual reality, telemedicine (teleconsulting and telesurgery) and the creation of experimental models. Minimally invasive surgery will unquestionably benefit from this progress with the possibility of extending its range of indications to procedures in which human limitations are more evident owing to difficulties of access and the size of the target, at the same time guaranteeing high-precision manoeuvres. In the oncological field, high expectations accompany the advances in our knowledge of molecular biology with the genetic mapping of tumours which may pave the way for screening programs and gene therapy. Alongside the scientific and technological development of the surgery of the future, we can expect to see the increasing emergence of: a) economic problems related to the progressive increase in healthcare costs, amongst other things as a result of the powerful impact of high-tech solutions; b) social problems in terms of the inevitable conflict between cost-containment policies and the right to healthcare; c) moral and bioethical problems relating to the possible establishment of genetic registries and to the different patient-care provider relationship which is likely to come about as the result of the interference of machines or robots. The surgeon's persona may undergo profound changes, not merely from the technical and professional training standpoint, but also with regard to his or her effective role, which may no longer be that of a central, dominant figure, but may be scaled down in a context of multidisciplinary co-operation.